What if Drugstores Sold Birth Control Without a Prescription?

Fran Kritz

About the Author

Fran Kritz is a veteran freelance health writer based in Washington DC and is a regular contributor for the California Health Report and the Washington Post health section.

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How many moms do you know who got pregnant with a second child before they intended to — or a third before they were ready? Maybe that even includes you? The actual number is high: About half of all pregnancies in the U.S. each year are unintended, according to the U.S. Department of Health and Human Services.

Now imagine that it was possible to simply drop by your local drug store and pick up a pack of birth control — without needing to call and visit your doctor. Giving more women easier access to effective methods of controlling their reproductive lives could have a big impact on that rate.

The idea of making oral contraceptives — a.k.a., the Pill — available without a doctor's prescription has been making headlines the past several months, in part because a number of candidates running in this year's midterm elections for Congress have proposed the idea in an effort to get the attention of women voters.

The proposal has the support of many physicians and doctor's groups, including the American College of Obstetricians and Gynecologists (ACOG), which this summer reaffirmed the position statement it issued two years ago advocating that birth control pills be sold without the need for a prescription to cut the time and money it takes to visit a health care provider. ACOG says eliminating that step would help reduce the rate of unintended pregnancies in the U.S.

Access and cost of birth control today

ACOG's position statement calls not only for prescription-free oral contraception but also insurance coverage for OTC drugs to reduce the barrier of costs for women who can't afford the drugs. Under the Affordable Care Act, the health insurance law that went into effect last year, just about all forms of contraception — including oral contraceptives — must be covered by insurance, unless the employer paying for coverage is a religious institution that objects to covering the cost of contraception. The current cost of oral contraceptives for women without insurance is about $60 per month. Surveys show that women say $20 is the average price they could afford each month.

Daniel Grossman, MD, who coordinates the oral contraceptive Over the Counter working group at Ibis Reproductive Health, in San Francisco, a nonprofit organization aimed at improving women's reproductive choices, says that some women in El Paso, Texas are legally getting the Pill over the counter in Mexican pharmacies. Research by Ibis has shown that compared to women who get the drug with a prescription at public health clinics in Texas, those who got the drug without a prescription stayed on it longer, because they didn't have the added step of contacting and visiting the doctor.

The Pill is safe, say experts

Grossman, who is also an assistant clinical professor of obstetrics and gynecology at the University of California, San Francisco, also points out that the Pill has successfully been on the market in the U.S. for more than 60 years. And studies have shown that low-dose formulations — the ones most commonly prescribed for birth control — are "unquestionably safe." Grossman says that while there are some conditions, such as high blood pressure, that might be an indication not to use oral contraceptives, women can generally identify those conditions themselves and choose another option.

"Over-the-counter oral contraceptives are a great idea," says Eve Espey, MD, MPH, an obstetrician/gynecologist in Albuquerque, NM, chairwoman of the ACOG's Committee on Health Care for Underserved Women. "It would improve access to oral contraceptives and likely reduce failure rates in women who run out of pills." Espey says that currently, a major barrier to access is the requirement that a woman visit a provider in order to obtain the Pill, and says this requirement is "ostensibly to ensure patient safety and has traditionally bundled the Pap smear and pelvic exams. In actuality," says Espey, "what is needed to safely prescribe the Pill is a medical history to rule out contraindications and for some patients, a blood pressure check. But studies have shown that women can reliably and consistently understand who should and shouldn't take the Pill as well as a clinician," Espey says.

Two years ago, for example, the Food and Drug Administration, which would have to approve an OTC version of the Pill, appointed an advisory panel to consider whether certain drugs, including birth control, could be safely switched to OTC status. A study presented at the meeting found that women were very able to answer questions correctly about their blood pressure and history of blood clots, both risk factors that can indicate the Pill could pose a health risk.

Concerns about OTC birth control

Although all oral contraceptives are considered extremely safe, estrogen-containing pills do have a higher risk of serious complications like heart attack, stroke or blood clots compared to progestin-only pills. Dr. Grossman says in because of that, he suspects the first Pill to be approved for OTC sale will be a progestin-only one — which is just as effective at preventing pregnancy.

Espey says that another concern posed about making the Pill OTC is that by reducing the need for women to see their gynecologist, women might not get tests for sexually transmitted diseases, including the Pap test for cervical cancer. However, "Studies do not indicate that women are less likely to receive such testing. And additionally, it doesn't make sense to hold one important service (preventing pregnancy) hostage to another important service," says Espey. "The example I have used is: doctors don't typically require men to have a colonoscopy in order to prescribe Viagra."

The argument for an OTC Pill

Espey says that studies also indicate that the most important predictor of success with the Pill is the number of packs a woman has on hand. "Insurance regulations that limit women to one to three months of Pills dispensed at a time are a major impediment to the correct and consistent use of the Pill." Espey also points out that OTC access would be "a major boon for underserved women who [often] do not have reliable access to health providers."

A national survey conducted by Ibis last year found that nearly two-thirds of women in the United States wish they could purchase their birth control pills over the counter, and about 30 percent of those surveyed who weren't currently using any birth control or were using a less effective method, such as a condom, said they would take the Pill if they could get it without a prescription. And, according to studies by the research group ThinkProgress, the majority of other countries around the world already offer birth control pills over the counter.

Questions about who will pay for the Pill

Some advocates of making the Pill available without a prescription are concerned the push by congressional candidates for an OTC birth control pill could leave many women to foot the bill themselves. Employers who are morally opposed to birth control could have an easier way to refuse to pay for coverage.

In a statement released this September 9, John Jennings, MD, ACOG's president, said, "Of course, cost continues to be a major factor in a woman's consistent use of contraception, and many women simply cannot afford the out-of-pocket costs associated with contraceptives, OTC or not. That's why ACOG strongly supports the Affordable Care Act (ACA) provision that mandates insurance coverage of birth control, as well as other preventive services, without cost-sharing for the patient."

Dr. Grossman says the most likely scenario for high use of OTC oral contraceptives would come from making the Pill both OTC and covered by insurance. There is precedent for that. Some insurers cover some OTC drugs, such as allergy medications, and several state Medicaid programs cover OTC emergency contraception without a prescription, as do the Indian Health Service and TRICARE, the insurance for active-duty military personnel and their dependents.

To actually get an oral contraceptive over the counter, a drug company would have to petition the FDA for the switch. Right now, no companies have done so, according to the agency.

Regardless, an OTC pill isn't a one-size-fits-all solution. Just because one type of pill is available at drugstores doesn't mean it's the right option for all women — which means there needs to be a discussion about other methods. "OTC access to oral contraceptives alone will not help to increase use of the most highly effective methods, such as intrauterine devices (IUD). IUDs are more effective than oral contraceptives, and because they can last for as many as 10 years, they are also cost-effective. However, their initial out-of-pocket costs — which can near $1,000 — can be prohibitive for women who don't have comprehensive insurance coverage."

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